What is the most appropriate next step in managing a 24-year-old woman with a 5-cm mildly tender left adnexal mass and a negative pregnancy test?

Management of a 24-Year-Old Woman with a 5-cm Left Adnexal Mass

The most appropriate next step in management for this 24-year-old woman with a 5-cm mildly tender left adnexal mass and negative pregnancy test is to repeat the examination in 2 weeks (option A). 1

Rationale for Recommendation

Assessment of Clinical Presentation

• Young premenopausal woman (24 years old)
• Regular menstrual cycles (28-day intervals)
• No medications
• Negative pregnancy test
• 5-cm mildly tender left adnexal mass

Why Repeat Examination in 2 Weeks is Appropriate

1. Functional Cysts are Common in Premenopausal Women

   • Most adnexal masses in premenopausal women are functional cysts that resolve spontaneously 1
   • The timing of the examination (3 weeks after last menstrual period) suggests this could be a functional cyst related to the menstrual cycle

2. Low Risk of Malignancy

   • In premenopausal women, US identification of a simple cyst establishes a benign process in 100% of cases 1
   • The patient's age (24) places her in a very low-risk category for ovarian malignancy

3. Clinical Guidelines Support Observation

   • The ACR Appropriateness Criteria recommends follow-up US for functional cysts to document resolution 1
   • Most nonsimple cysts in premenopausal women are also functional and will resolve spontaneously 1

Why Other Options Are Not Appropriate

Measurement of Serum CA-125 Level (Option B)

• Low specificity in premenopausal women
• Often elevated in benign conditions including endometriosis, fibroids, and during menstruation
• Not recommended as an initial test for adnexal masses in young women without high-risk features 2

Measurement of Serum α-Fetoprotein Level (Option C)

• Not indicated as an initial test for evaluation of an adnexal mass without specific features suggesting germ cell tumor
• No clinical features in this case suggest a germ cell tumor requiring AFP testing

CT Scan of the Pelvis (Option D)

• Not indicated for initial evaluation of adnexal masses
• ACR guidelines state: "CT pelvis with IV contrast is usually not useful in further characterization of indeterminate adnexal masses" 1
• Unnecessary radiation exposure in a young woman

Diagnostic Laparoscopy (Option E)

• Overly invasive as a first-line approach for a likely benign condition
• Surgical exploration of benign lesions has reported complication rates of 2-15% 1
• Should be reserved for cases with concerning features or persistent masses after observation

Management Algorithm

1. Initial Follow-up (2 weeks)

   • Repeat bimanual examination
   • If mass has resolved → no further workup needed
   • If mass persists → proceed to imaging

2. If Mass Persists After Follow-up

   • Obtain transvaginal ultrasound (first-line imaging)
   • Include color/power Doppler to evaluate vascularity 1

3. Based on Ultrasound Findings

   • Simple cyst → continued observation
   • Specific benign features (endometrioma, dermoid, etc.) → appropriate management based on diagnosis
   • Indeterminate or concerning features → consider MRI pelvis for further characterization 1

Important Clinical Considerations

• Warning Signs that would alter management:

  • Solid components in the mass
  • Thick septations (>2-3 mm)
  • Increased vascularity on Doppler
  • Presence of ascites
  • Mass >10 cm 3

• Timing Matters: The proximity to menstruation is important - functional cysts often resolve within 1-2 menstrual cycles

• Common Pitfall: Rushing to invasive procedures or advanced imaging for likely benign adnexal masses in young women, resulting in unnecessary procedures, anxiety, and potential complications